Saturday, October 17, 2015

Epstein on Natural Law, Ancient and Modern

A few brief thoughts I may return to later, time and study permitting.

One of the many wonderful things about our modern life is how quickly and easily accessible things are which would have been either inaccessible or time-consuming to access just a few brief years ago.  I recently stumbled upon a couple of Richard Epstein talks recorded on youtube.   They virtually allow one to attend those talks from the past – from any time and place.  How remarkable, if you pause for a moment to not take the development for granted.

This one here, in particular, is well worth watching:

It is entitled “Natural Law in Ancient and Modern Guise.”  It is from 2010, and runs about one hour, with extra time for questions/answers. 

Epstein, a prolific academic writer and thinker, speaks, as always, in complete paragraphs, quickly and effortlessly.  He clearly knows his topics backwards, forwards, and sideways.  Even if one is inclined to disagree with him altogether, or in part, it is always most challenging and rewarding to hear the opposite side of the argument cogently argued.

For those inclined to agree, watch it twice. 

Or thrice.

I find that many who think well and deeply about political theory and philosophy are relatively uninformed about, or ignore altogether, economics and the revolution in economic life over the last quarter millennium.  Economists, however, often have a naïve or diminished view – or even an unmanly contempt for - the political and cultural structure that necessarily provides the foundation for a free and peaceful economic life.  

Epstein falls into neither camp.  He has a commanding grasp of both economic theory and of political philosophy.  He comes at all this, somewhat uniquely, from the standpoint of the law, and as a law professor.  As a non-lawyer I find this intriguing.  When he talks about economics and political theory, he typically thinks about not just the theory and broad “constitutional” questions (meant here not to only refer to the US constitution) but also the very specific legal issues that arise.  His description of Roman law and the pre-Thomistic “natural law” is fascinating.   He ties this to Anglo-American law, written and unwritten.

(There is also an insightful question and answer exchange around the question of natural right and natural law.  One is reminded that Leo Strauss pointed out that the ancient philosophers contrasted “nature” and “law/custom[nomos].”  Justinian Roman law, one assumes, could think about laws which are natural [not customary] since the Empire had created a universal political and legal system, a situation distinct from that of the ancient city).

Epstein's strong preference is for the classical liberal position, in politics, in law, and in economics.  He explains how these are intrinsically linked.

The concluding remark is this:  “Essentially the lesson is, unless you can master the ancient conceptions of natural law, you will never be able to do modern public policy well.”  How he gets there is an hour well spent.

Epstein also has a “new” book out (2014) that is on my list to read.  “The Classical Liberal Constitution: The Uncertain Quest for Limited Government”

Amazon link:

He gives another fine talk on that book and on Hayek here:

Friday, July 3, 2015

The Best Defense is to Take Offense?

This week Dr. Bob Wachter wrote a blog post that is the first attempt I am aware of by a member of the ABIM leadership to defend the organization against the now widespread allegations of egregious waste and derelict stewardship.  It can be read here:  "The ABIM Controversy: Where the Critics are Right, Where They’re Wrong, and Why I Feel the Need to Speak Out."

He starts his piece in a pique of moral indignation: 

With the help of social media and a journalist who has turned this matter into a cause célèbre with an unfortunate mixture of half-truths and innuendo, the critics have managed to control the debate, and people who believe in the values of the Board have been cowed into silence. It feels vaguely McCarthyish, and there comes a time when silence is immoral. This feels like such a time.

Joseph McCarthy was of course the U.S. Senator interrogating possible communists.  However, an investigative reporter, an electrophysiologist blogger, et al. do not sit in the seat of power.  No, it is the ABIM that holds great power over the lives and careers of 200,000 physicians in this country.  Indeed, if one must use a 20th century Republican politician’s name as an adjective appropriately in this case to describe a person who holds a position of great responsibility and power and believes himself to be persecuted against all evidence, the correct word is:  Nixonian, and it applies not to his detractors but to the good doctor himself.

Now, there are many aspects of this ABIM controversy.  They include, but are not limited to 1) the issue of certification, re-certification, MOC, etc. 2) the existence of, reason for, politics of, and funding of the ABIM Foundation, and 3) the financial details.

In the interest of space and time, and since it is covered so exhaustively elsewhere, I will leave aside #1 and #2 for now. 

Regarding number 3:  After reading Dr. Wachter’s post I have re-watched Dr. Cutler’s debate with Dr. Baron from December of 2014 and re-read Dr. Westby Fisher’s posts and Kurt Eichenwald’s Newsweek stories.  What does Dr. Wachter have to say about the allegations of egregious waste, lavish spending, exorbitant salaries, and derelict stewardship of trust and resources?  Does he dispute the facts?  If not, does he offer an explanation that addresses the specifics? 

Let’s looks at his piece.  Against the charge that “The Board is All About the Money” he writes: 

As Board members, we constantly struggled with balancing our fiduciary responsibility to the organization (including to pay the salaries and the costs of doing the Board’s current work and innovating) with the burden to the diplomates. ABIM’s MOC process currently costs physicians about $200-$400 per year (the low end for the internal medicine certificate only; the higher range is for those maintaining multiple certificates, like IM/cardiology/interventional cardiology). These costs are consistent with the fees of other ABMS boards. The argument that this represents an impossible expense to the vast majority of practicing physicians is hogwash.

That’s it.  They “struggled,” and the cost is not that much per person anyway, so “shut up” (leave aside for the moment those that dispute the true cost). [Edit 7/7/15 I will add that it should go without saying that when the Board authorizes wasteful spending it does neither its fiduciary duty to the organization nor its duty to the Diplomates]

His section regarding salaries and the Condo is equally pithy.  He only addresses the CEO’s salary, for example.  Let’s ignore that for now and assume the CEO deserves every penny. If I round up to one million for his salary/benefits, we are still left with salaries/benefits for the ABIM and its Foundation of $29,000,000/year!  This is to run what should essentially be a testing and record-keeping company, if a large and sophisticated one at that.  And again, this is not the budget, just the payroll.  What about the assistant to the President who Dr. Cutler pointed out made $689,000 in 2011?  Do we finally learn her job description or why she was worth this from Dr. Wachter?  He was on the Board of Directors at the time and presumably voted on the budget.  No, it’s not mentioned.  How about the two researchers on the benefits of MOC who made $450,000/year?  Are the salaries mentioned?  Is the embarrassing conflict of interest mentioned?  No, nothing.  Even the “Senior Vice President of Communications” reportedly was compensated $293,000 in 2013.  The point is it takes a lot of employees earning large salaries to reach a sum of $29,000,000/year.   I should point out that these are not my facts.  I am simply repeating what I have seen and read reported.  No one from the ABIM has substantively disputed the numbers, nor defended them.  Despite the length of his post, Dr. Wachter also simply ignores them.

Regarding the Condo he essentially admits that it looks bad, but was really “designed to be revenue neutral” compared to hotel room costs for consultants.  This is thin gruel, if not outright laughable.  First, the only reason to buy rather than rent is to save money, not break even; and if looking to save money Dr. Cutler points out less expensive units practically across the street.  He relates having been told that the Condo the ABIM did purchase was the most expensive real estate in Philadelphia per square foot!  One comes to the inevitable conclusion that thrift was not exactly a concern at the ABIM in those days.  With the caveat that any analysis of the finances of the condo vs. hotel rooms obviously leaves aside the fact that the condo would not suffice if more than three rooms were needed at a time, let’s take a quick look at the numbers.  Traditionally, financial theory in retirement has suggested that 4%/year may be spent from a well-invested nest egg without affecting the long-term real principal.  Some argue that this is too high given today’s interest rates and equity valuations.  So, let’s be very conservative and take 2.3 million invested in index funds and treasuries, and spend 2.5%/year on hotel rooms.  This comes to $57,500/year.  The condo’s expenses (not taking into account depreciation) were roughly $42,000/year (per Dr. Wes’ post).  So we have at least $100,000/year in hotel costs that the condo represents if “revenue neutral.”  I will let this speak for itself.

As we see, then, Dr. Wachter does not seriously address any of the allegations of financial waste that have come to light in the last seven to eight months.  On salaries, Four Seasons meetings, etc. he simply ignores most of the points made by Dr. Cutler in December, let alone the mountain of additional information that has surfaced since.  In the end, one can only assume that he neither disputes the facts of the allegations nor defends the ABIM’s actions (assuming the facts correct) for a simple reason:  There is no credible defense.

In his penultimate paragraph he states:

I further believe that this process must be crafted by members of the profession itself – and if we abrogate that responsibility, others will fill the void.

Well, to that a great chorus of readers cries out:  “If the unelected, unaccountable, unrepresentative, monopolistic, and profligate ABIM is self-government, then give me George III.”

He ends with a martial metaphor:

“Throw the bums out!” can feel like progress. But, as the Arab Spring protesters have learned, sometimes it’s relatively easy to tear down institutions. Rebuilding them is much harder.

This is hyperbole, or course, but I will indulge it.  It is true that more often than not bloody political revolutions and coups do not turn out well.  There is a document, 239 years old tomorrow, that addresses this fact:

Prudence, indeed, will dictate that Governments long established should not be changed for light and transient causes; and accordingly all experience hath shewn, that mankind are more disposed to suffer, while evils are sufferable, than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism, it is their right, it is their duty, to throw off such Government, and to provide new Guards for their future security.

Busy internists are not your typical torch and pitchfork crowd.  Prudence is their virtue. 

I do not know how this controversy will ultimately end, but I do know that Dr. Wachter’s post is not an apology, not an adequate defense, and not a way forward.

Wednesday, April 29, 2015

Why the ACP needs to comment on the ABIM scandal

It has been now over four months since Dr. Wes Fisher’s post on the ABIM luxury townhouse and since Dr. Charles Cutler’s debate with Richard Baron: events which began the exposure of the details of the ABIM financial scandal. 

It has now been roughly two and six weeks respectively since Kurt Eichenwald’s Newsweek articles on the ABIM and its financial scandal.

While they have commented on the maintenance of certification process at the ABIM, the American College of  Physicians - which regards itself as the organization for internal medicine - has yet to issue a statement regarding the ABIM financial scandal or its details. On the ACP advocate blog  (authored by Bob Doherty, ACP’s head lobbyist) over this period of time, one can read about not just the recent SGR saga, but also handguns, and on his twitter feed he shared a story about the POTUS and the new Surgeon General addressing the “health effects of climate change.”  However, nowhere is there any coverage of this huge story, a scandal that directly affects internists.

So:  Handguns and Global Warming from the ACP, but not a word on these very serious allegations of fiscal impropriety at the certifying board.

How can this be? 

Some suggest that the ACP has a conflict of interest in that they profit from test prep materials and courses. 

Some also suggest that there is a revolving door, of sorts, between many of these organizations.  A case in point:  the former longtime CEO of ABIM, Christine Cassel, has listed on her bio at the National Quality Forum that she is a Master of ACP and former President of ACP.  So far as I know, no one at ACP has publicly questioned her leadership while at the ABIM.  

For the moment, however, put aside these thoughts.  Moral courage (to overstate the ethical requirements in this case, certainly) is not doing the right thing when it easy and profitable.  Quite the contrary, courage is doing what is right when it is difficult, or otherwise against one’s personal interests.

The ACP should do what is right on behalf of its current and potential members and publicly express concern about the allegations of financial mismanagement at the ABIM. At some point, the failure to condemn is to condone.  That point, if not yet behind us, will be past soon. 

In the end, can a voluntary organization afford not to speak on behalf of its dues-paying members when the cause is right?


Newsweek articles:  

Tuesday, March 10, 2015

The Board of Directors at the ABIM: Will they defend their record? Or were they apathetic, incompetent, or deceived?

For readers that would like more detail, I will refer to my prior post, as well as to Dr. Westby Fisher’s comprehensive coverage of the ABIM scandal, on his blog:

Today, in Newsweek, Kurt Eichenwald wrote a piece, that updates this scandal on a mainstream media site. Link here:

With gems such as: “…the ABIM went from being a genial organization…to something more akin to a protection racket.” And, best of all: “the ABIM Foundation that does…well, it’s not quite clear what it does. Its website read like a lot of mumbo-jumbo.”

So, we have here a protection racket with its spin-off “mumbo-jumbo” cousin. For those counting, that’s mumbo-jumbo with a $30,000,000/year payroll (not total budget, just salaries and benefits between the two organizations! [source: tax records as documented by Charles Kroll]).

All of this brings me to this point. Some like to imply that blame for this scandal should be placed mainly on the prior president/CEO (the beleaguered Christine Cassel, currently the head of the National Quality Forum, who was forced to resign last year from high-paying corporate boards due to serious conflicts of interest:

However, sitting on the board of any organization is a serious endeavor that deserves to be treated as such. It is not only a CV-builder and not only a place to nurture relationships. Unless they can prove that they were actively deceived by Dr. Cassel, et al., the board members past and present are ultimately responsible for what the ABIM has become. The current names and bios of board members are readily available at the ABIM and ABIM foundation websites.

These men and women who have served on the board of the ABIM over the last ten to fifteen years have only two possible primary responses to this scandal and their involvement with it:

1) Defend the organization as currently constituted.

No human institution is perfect, of course. An adequate defense, however, would recognize that while there will always be minor shortcomings a clear and convincing argument is necessary regarding both the charges of impropriety (luxury townhouse, etc.) and how it is that the ABIM needs a thirty million dollar payroll. It is not easy to imagine such an argument being a cogent one.

2) Demonstrate that he or she actively voted against or otherwise fought against these developments.

Other than 1 or 2, the only other possible explanations for the board members' work at ABIM are the ones I list in my title: apathy, incompetence, or having been deceived by the leadership.

Which is it?

Monday, February 9, 2015

Five Questions for Richard Baron

First some background:

There is controversy of late regarding the ABIM (American Board of Internal Medicine) and its financial dealings. Allegations range from poor fiscal stewardship to worse. This includes the purchase (and now sale at a loss) of a 2+ million dollar condo in Philadelphia, etc.

Dr. Westby Fisher’s blog has many of the details and links:

Original piece on the condo:

Description of a Philadelphia medicine town hall meeting regarding ABIM and MOC, but also the condo, salaries, poor stewardship of funds at the ABIM, etc. featuring a debate between Charles Cutler (former chair ACP board of regents) and Richard Baron (CEO of ABIM):

Not to be missed is this excellent video of that debate:

All of which leads to my five questions for Richard Baron, CEO of ABIM:

1. Do you dispute Dr. Cutler’s facts from your recent debate with him in Philadelphia?

2. Were you the Treasurer of the ABIM at the time of the condo purchase?

3. What is the job description of the non-M.D. employee (assistant to the president) at ABIM who made $700,000 in one year?

4. As a follow-up to #3, do you stand by your reply to Dr. Cutler that “salaries get set as salaries get set?”

5. Depending on your replies to questions #1-4, how does ABIM have credibility when it comes to hectoring physicians on the cost-effective use of limited resources?